"Increased rates of discharge home and a reduced length of stay make this strategy more efficient than traditional care," say Harold Litt (University of Pennsylvania, Philadelphia, USA) and team in the New England Journal of Medicine.

Patients in the CCTA group underwent CCTA as the first evaluation. In the traditional care group, the patient's healthcare provider decided which tests, if any, were to be performed.

In both groups, management of the patient's condition and the decision regarding admission or discharge were at the discretion of the treating clinician, "thereby reflecting real-world practice," say Litt et al.

Of 640 patients with a negative CCTA examination, none died or experienced myocardial infarction within 30 days, which was the primary safety outcome of the study. "Thus, the results meet the prespecified safety threshold (upper limit of the confidence interval, <1%)," note the authors.

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Compared with patients who received traditional care, those in the CCTA group were significantly more likely to be discharged from the emergency department (22.7 vs 49.6%) and had a shorter stay in hospital (median 24.8 vs 18.0 hours). They also had a higher rate of coronary disease detection than patients who received traditional care (9.0 vs 3.5%).

There was one serious adverse event (bradyarrhythmia) in each group, but the authors believe that in both cases this was likely to have been caused by medications used for heart rate control.

"Since low-to-intermediate-risk patients account for 50% to 70% of presentations with a possible ACS, we believe that a CCTA-based strategy can safely and efficiently redirect many patients home who would otherwise be admitted," Litt and co-authors write.

They conclude: "Whether earlier identification of coronary disease will lead to preventive therapies that improve long term outcomes requires further study."